Audit Problems

[RR1]

Looking back on one of the polls on BBT shows that folk are finding most difficulty with auditing. Is this due to the lack of templates or other reasons?

This site is all about helping each other, if you could post the problems you are experiencing with this we could try and solve some of these issues together.

I would love to see a database of lots of different audit templates for us to share- it can't really be that difficult to achieve if we all contribute just one.

thoughts on this please!

[adiescast]

I think many of the problems with auditing have to do with getting it up and running as a manageable part of daily life. Having the templates would be a great start. It looks like the BBT library could be a good place to do this. AABB also has some templates in their Commendable Practice section.

Advice on how to manage auditing with the available time and resources would also be helpful. Many small places have only one person to do all the work and all of the management and quality tasks. This can be quite daunting, particularly if they have never performed any audits. Medical technology schools should take note, if they have not already, to add audit training to their programs!

[LAS]

We do a brief audit montly. We pull a list of approximately 10% of tranfusions and review the charts for:

Signed consent

Physician order

Clinical indication for transfusion

Record of transfusion (bedside checks, vitals, 2 signatures, etc.)

Transfusion reaction record if indicated.

Response to tranfusion

This information is summarized and reivewed by my organization's transfusion subcomittee (part of our overall P.I. group). We also include # of products transfused, C:T ratio, and wastage.

We were told that chart review was being done by our medical records department, which of course was not - at least not in any form even close to adequate. From the information gleaned from these reviews we have modified a couple of the forms that the nurses use (with input from nursing as an attempt to increase documentation compliance), identified a physician who abuses the autologous protocol, identified a nursing unit ordering FFP inappropriately, determined that tranfusion reaction records were not being charted appropriately, revised the tranfusion record for the surgery department, and identified nursing units with patterns of non-compliance.

Our nursing V.P. was astonished at the inadequacies of some of the documentation, so she started taking names and kicking ****. It has gotten much better. Now they do it not because they understand why, but because there will be hell to pay from her if they don't... whatever works I guess.

This is probably less than many institutions do, but it works well for us.

[RR1]

I think many of the problems with auditing have to do with getting it up and running as a manageable part of daily life. Having the templates would be a great start. It looks like the BBT library could be a good place to do this. AABB also has some templates in their Commendable Practice section.

Advice on how to manage auditing with the available time and resources would also be helpful. Many small places have only one person to do all the work and all of the management and quality tasks. This can be quite daunting, particularly if they have never performed any audits. Medical technology schools should take note, if they have not already, to add audit training to their programs!

Do you think the AABB would mind folk sharing their templates with this site- or am I just pushing my luck?

I know some places have a Pathology audit team which takes care of this aspect, but most of us seem to be auditing our own areas- which isn't good practice. It would be an excellent idea to include audit training at technology schools/ colleges. I think GMP training should also be part of the curriculum.

[RR1]

Thanks LAS, you seem to be working well with the clinical teams and making improvements, which is basically what auditing is all about.

In the UK we also have to audit against the Blood Safety and Quality Regulations -to ensure we cover all the major aspects of this, which includes traceability of components, recall systems, incident reporting etc. Trying to keep on top of this additional workload can be difficult, so we need to find and adopt smarter ways of working to cope with it all.

[RR1]

There are a few audit templates now within the library area of this forum. If anyone would like to contribute by submitting some of their own, this would be really appreciated by most of us on BBT.

You could either submit these yourselves, post them on this site so they can be transferred over or email either Cliff or myself and we will attach them. If we can really fill this database would save us all a lot of time and effort, they don't have to be works of art- just useful!

many thanks

[kate murphy]

Here are a few audit templates that we do.

1. blood admin audit - we actually follow a blood component to the nursing unit and watch the process, similar to CAP, AABB and JC. Time consuming, we only do 3-4 per month.

2. OB audit for adequacy of RHIG dosing. Retrospective. ID all RH Neg moms with Rh Pos infants, check FMH done and check calculation of RHIG dosing.

Both of these audits are reported to Lab QA, Hosp QA, and directly to Nursing VP/Directors. After nursing's first initial shock, they are cooperative and nursing leadership likes the audits.

Blood Administration Audit.doc

FMH RHIG AUDIT.doc

[RR1]

That's really kind of you Kate- I will ask Cliff if he can load these into the library, Thanks very much!!!

[Cliff]

That's really kind of you Kate- I will ask Cliff if he can load these into the library, Thanks very much!!!

Thanks for the suggestion, I copied them to the Document Library